Batushkin V. V.1, Herman N. A.2

Low-­Renin Hypertension, Poly-­resistant to Therapy. The Experience of Successful Treatment

Abstract

The case of low-renin arterial hypertension (AH) resistant to basic drug therapy is presented and the algorithm of proper drug treatment is provided.

A female patient 72 years old complained about tension-type headaches, fatigue, weakness, anxiousness, associated with periodic blood pressure (BP) rises to 190-200/90 few times per day. A long duration of the disease and the absence of stable treatment effect led to mental exhaustion, emotional instability, sleep disturbance. The combination of perindopril-indapamide-amlodipine was taken by the patient in maximal dosage. Electrocardiography and echocardiography showed the features of modest left ventricular hypertrophy. Diastolic disfunction was presented by impairment of relaxation. The diagnosis was: arterial hypertension, ІІ stage, grade 2, risk 3. Crisis course. Asthenic vegetative syndrome.

Such medications as nebivolol, passiﬂora extract were added to previous drug therapy.

After a week of treatment, the general state did not improve. On a 24-hour basis immediate, not provoked by external factors rises of BP to 180-200 mm Hg occurred. The patient tried to manage the episodes by captopril with hydrochlorothiazide, farmadipine.

Taking into account the insufficient effect of complex hypotensive therapy and general state, the patient was hospitalized on 30.04.2019. Instead of perindopril, telmisartan (inﬂuences on vegetative balance) in dosage 80 mg per day was prescribed, instead of nebivolol, carvedilol (has an additional alpha-blocking effect) was prescribed. Indapamide and amlodipine were still presented in therapy. Taking into account psychasthenic events of somatoform disorder, amitriptyline was also prescribed to the patient in single-daily dosage 0.25 mg in the evening.

During the next few days, the number of hypertensive crises decreased, however headache and weakness were still present because of BP rises throughout the day. Taking into account insufficient (subjective) hypotensive treatment effect, 24-hour automatic BP monitoring was conducted, due to which the numerous BP rises were registered in the day time(maximum to 182/98 mm Hg). In 10 days regardless therapy modification, which included telmisartan replacement by lisinopril, lercanidipine 10 mg prescription instead of amlodipine (the patient complained about oedema), the addition of veroshpirone 25–50 mg, the rises of BP up to 170–180/90–100 mm Hg remained. That was treated by additional administration of urapidil, magnesium sulfate infusions, diuretics. Regardless of normal sonography measures of adrenal glands, the normal rate of Potassium in serum (4.2 mmol/l) and veroshpirone hypotensive effect insufficiency, the patient was directed to the further examination of adrenal pathology.

Within daily diuresis 2650 ml such results of laboratory tests were received in a vertical position during the first two hours after sleep: active renin < 0.01 ng/ml (normal 7,54–42,3), aldosterone 7,5 ng/ml (normal 7–30), metanephrines 46,9 mcg/24 hours (normal 25–312).

Taking into account the low level of renin with normal rates of aldosterone and metanephrines, the medications, which block renin-angiotensin-aldosterone system (RAAS), were canceled and moxonidine in dosage 0,3 mg twice per day was prescribed. During the next 4 days of ambulatory monitoring, BP was stable with maximal rates 120–130/60–70 mm Hg. Catamnesis: in 8 days patient reported by phone about a gradual decrease of systolic BP to 110-120 mm Hg and the absence of hypertensive crises. The next 24-hour automatic BP monitoring observed the mean BP level 118/75 mm Hg (maximal 134/93 – during load).

Taking into consideration the levels of minimal and maximal BP during the day, the dosage of moxonidine was recommended to be decreased to 0.2 mg twice daily.

During the discussion, the specificities of moxonidine usage in patients with AH with and without comorbidity are presented and the results of comparative studies are provided.